Midwifery Today Community

 Hi Everyone!

I would appreciate your input on my situation.

I have two children.  With both births (in hospitals w/ CNMs), I had a fourth degree lacerations.

We want more children.  But as you can probably tell, I am not looking foward to the perineal trauma.  As birth professionals, would you:

A) recommend a homebirth/waterbirth

     or

B) recommend an elective c-section for subsequent births???

Thanks!!!!

 A little background on the births would be helpful, yeah???

BABY #1:  38 hr. labor, no epidural, meconium present, pushed for 3+ hrs., pren-massage,  lithotomy position, midline episiotomy, grade 4 laceration.  Keep in mind that I also have a short perineum.  8 lbs. 9 oz. 22 in

BABY #2:  16 hr. labor, epidural, meconium present, pushed for 45 min., lithotomy position, pren-massage, no episiotomy, shoulder dyscio., grade four lac, 10 lbs. 12 oz. 23 inches

I realize there are controllable factors that could have led to the fourth.  Then, there's the short perineum (1/2 inch of space between vagina & rectum).  Part of me feels a homebirth setting could improve the perineal outcome for the future.  And the other part of me wonders if I'm destined for a surgical birth with two fourths already.

I'm very open to your opinions/recommendations.

Also, I'm sure you're well aware of the pressure I faced when pregnant with BABY #2.  Any OB would have been quite pleased to hear me just say the word. ;)

Greetings!  How many stitches did you require?  Perhaps that isn't even an important question, but wondered if you had any idea? 

My SIL had baby #1--epidural, and all the trimmings...every side effect from an epidural happened to my SIL> she got  a bonus too, an internal laceration...just about the entire length of her birth canal... the attending physicians could see into her body cavity...worst they had ever experienced...she was in surgery for close to 3 hours for repair. 

baby #2  caeserean birth

baby #3  she wanted to try a vbac...not wanting to have the longer recup time with another c-section, but not wanting to have another terrible tear..internally or externally.  all of the medical profession were telling her that her tissues would be brittle, non-elastic, and her chances of tear were 100%.   we were very aggressive with good nutrition--making it excellent nutrition...including vitamin E (the amount escapes me now, but I could look back and see what we did)...perineal massage beginning at 36weeks...lots of kegelling...good walking exercise each day...she had the most magnificent 3rd birth... everything she ever dreamed of, including a baby born in the veil.:)

I said all of that to say that I believe with some excellent prenatal care of yourself and a good communication with your care giver, you can have a birth without trauma to your bottom.

The first three of the eight babies that came through me, came with episiotomies ( the routine kind) in the hospital, but the last 5 born at home with a caregiver who paid particularly close attention to helping me have a slow, gentle birth...came without leaving a trace :)  Anything that you can do to encourage and increase circulation and elasticity in those tissues will be beneficial...warm bath, massage, keeping track of good nutrition and exercise, keeping baby in proper position, a slow birth--the shoulders are usually the culprits, snagging on their way out. 

hope some of this might be helpful to you.

Stay in touch

 Several things popped out at me:

Thing One:  Consulting another midwife (or two or three) and reconsidering birth place.

Thing Two Perhaps getting off your back and either onto your hands and knees or at least onto your side would help.  Many women do find, however, that they have less trauma in the warm water of a birthing tub/pool.

Thing Three:  Using what books call "physiologic pushing" rather than directed or "purple pushing".  ("PushpushPushPUSHPUSHPUSH!" while your face blotches out.) Pushing only when you feel the urge to push (hence the word "physiologic") and being in a gravity assisting position might be better on your bottom.

Thing Four:  Stop listening to folks who are telling you your body's been manufactured wrong.  You came off the assembly line just fine.  Working with your body rather than against it may just be what you need.

 A number of things come to mind...first of all, positioning.  Lithotomy or semi-sitting doesn't allow your tailbone to move out of the way for baby, and you end up having to push much harder, and stop listening to your body just to get baby out.

Second: IV use and the epidural.  I know you didn't have an epidural with the first, but did you have an IV?  The use of an IV overloads your body's tissues with fluid.  This can make the perineum more susceptible to tearing, the tissues are "water logged".

Third: get a new practitioner.  Look into homebirth.  My last client who had a 3rd (almost 4th) degree tear with the first (in a hospital induction with semi-sit delivery) laboured in private in the hospital with her second, we kept the lights out and when completely dilated she tried one push in the bed....then we requested that she be able to go to the bathroom to push on the toilet.  Babe ended up being born as she squatted on the floor at the foot of the bed.  Tearing was 2nd degree, and it should be noted that this baby was a full 2 lbs larger than the first, weighing in at just over 10 lbs.

 Oh, I meant to explain "laboured in private"....we kept all the lights out except for one small lamp, she spent a lot of time in the bathroom with hubby and myself.  We lucked out with a hands off nurse, who checked in on us during second stage with a flashlight and a hand held doppler.

 I am not a birth professional (first off so that you take that into account! :)).

I would say positioning and a very slow 2nd stage would help you.

For what it's worth i have a short perineum (about 1.8cm) and though i did have a small tear from DD's hasty exit it certainly wasn't major damage.  My midwife didn't believe i was in "real" labour until DD was crowning (thanks NHS!  At least i got a homebirth i suppose!) so my second stage was very long.  Her shoulders did indeed snag as she sailed out of me the one time i actually DID push, but it was really no big deal.  it was into the muscle and the midwife offered to stitch it but she also noted that though it seemed deep on my little perineum in fact it was very small in and of itself.  I declined stitches and it healed up fine.

I would consider homebirth.  And i would consider using hypnobirthing and a birth stool so you can sit and rather than pushing hard just push gently when you really want to and let the baby descend naturally with the help of gravity.  Hypnobirthing can be really helpful staying peaceful in the face of powerful sensations (and unhelpful "coaching"!).

Bec

 This was in the latest edition of Midwifery Today's e-newsletter. You may want to explore further info at www.midwiferytoday.com:

Sometimes a baby comes shooting out like a bullet with no tearing at all. Other babies ease out nice and slow, and a tear occurs anyway. To some degree, it is necessary to move beyond the issue of tearing and onto the larger picture of the birth experience as a whole. We must resist becoming too set in our ways. We must try to see each woman's unique needs and experiences. One of the many beautiful things about the midwifery model is the degree to which the midwife and client get to know one another. Ideally, the midwife will know what importance the client places on the possibility of tearing, which will help the midwife know how to proceed during the birth. Hopefully, the client will trust the midwife and be willing to do some type of prenatal preparation.

— Melissa Schuppe
Excerpted from "The Perinuem and the Birth Environment," Midwifery Today, Issue 65
View table of contents / Order the back issue

Obviously, your 4th degree isn't what you might call your "unique needs and experiences" but you may find more info to help you with your decisions by poking around the MT site articles and ordering back issue #65. HTH!

 1st, lithotomy position is usually not the best for keeping the perineum intact.  Try a different position next time. On my side worked best for me, but everyone must find their own best position. Experiment with different positions before labor.

2nd, once you feel that "ring of fire", gently breathe baby out, rather than using the old gut-busting pushes.

3rd, massage Vit E oil into your perineum daily for the last month to help it stretch. Good nutrition in general  also helps to have healthy, stretchy perineal tissue.

4th, Don't tense up, relax through the contractions to let it stretch gradually.

5th, if you have a hx of sexual abuse, you may have too much scar tissue to stretch normally. In this case a big episiotomy is still less traumtic, with less morbidity than an abdominal incision (C/S).

Waterbirth would be good or definitely try a standing up birth. It is so much more physiological. Just don't lay or semi sit. I would also recommend prenatal perineal massage in your case. 

 Last year I had 2 women, repeat ladies who had both experienced 3rd degree tears (thru the anal sphincter but not into the anal mucosa) with thier first babies.  One woman birthed on her side, small graze, nothing worth suturing.  The other opted for a planned lscs.  The difference was the first lass had no long term problems with bowel control after her tear, whereas the second had experienced 6 months of fecal incontince after her first baby.  Each mum did what she felt was the best option for her and her family and each was happy with their choice.

All i can do is recommend you educate yourself, read, talk to people, sit down with your partner and go thru all the options, all the good and bad of each decision and each possible outcome.  Get a second and third opinion.   Any position you give birth in in which you are not on your tail bone would be a good choice.  Good luck in your journey